The Super Utilizer: what you don’t know and

what you can do to helpJESSIE HIGGINS, MA, LPC, LMFT

STRAC SOUTHWEST TEXAS CRISIS COLLABORATIVE

What is the Southwest Texas Crisis

Collaborative?

The Southwest Texas Crisis Collaborative (STCC) is a division of STRAC, focused on ending ineffective utilization of services for the safety net population at the intersection of chronic illness, mental illness, and homelessness in San Antonio, Texas and Bexar County.

STCC is committed to improvement by developing a comprehensive, integrated crisis system across all major public payors, hospital providers, philanthropy, public safety (Fire/EMS and Law Enforcement) and behavioral health providers.

This initiative hopes to provide an unprecedented opportunity to create impact in the larger SA/Bexar County community, and be a part of systems change that will hopefully serve as a model to be replicated across Texas and the country.

Why is the Southwest Texas Crisis Collaborative?

What is a Super Utilizer?

$1.1 Billion

Safety Net Population

$200 Million

Mental Health Population

$80 Million

Homeless Population

$19 Million

High Utilizer Target Population

313,985 Safety Net

1,121,629 Encounters

33,810 Mental Health

320,350 Encounters

14,614 Homeless

109,432 Encounters

500 Target

Group

11,589

Encounters

3,507 Super

Utilizers

62,504

Encounters

$175 Million

Source: CHP Study

What is a Super Utilizer?

The Robert Woods Johnson Foundation defines Super-Utilizers as individuals whose complex physical, behavioral, and social needs are not well met through the current fragmented health care system.

In Capital Healthcare Planning’s initial analysis, “Super-utilizers” are defined as Safety Net patients who had:

Inpatient - 3+ discharges or had both a serious mental health diagnosis and 2+ discharges

ER utilization – 9+ visits

Exclusions – Pediatric Cancer Care, Neonatal

Who is a Super Utilizer? Jim

Schizoaffective disorder, past drug use, epilepsy/seizures, limited family support, low SES, unfunded, no access to medications

Came from out of town 6 months ago to live in a half-way house

3 months ago, moved into LMHA supported housing after being in and out of the hospital

Transferred to my case load as part of the ACT team and immediately needed to move out of the LMHA supported housing because of 3 month limit. One of my first clients on my own

Took him to Haven for Hope and he was intimidated by the size and scope. Could not get a bed as a member because he was not a resident of Bexar county, did not feel comfortable in the shelter side.

Started feeling overwhelmed, paranoid, and suicidal

Went to the closest ER, they held him for a few hours and then were discharging him

Felt like there was no place for him to go and felt overwhelmed, cut arm in ER.

Got admitted to inpatient, was given an additional diagnosis of malingering

When discharged, went to Salvation Army. Was able to stay at Salvation Army for many weeks, around 3 months, started working and contributing. Had a massive seizure while cooking in the kitchen, woke up in ER, and was not allowed back into the program.

All the while we were working on his medications, benefits applications, family relations, coping skills, etc…

mental health diagnosis

housing issues

limited social support

no money

Emergency Department?

Why is a

Super Utilizer

found in the

Emergency

Department?

Maslow’s

Hierarchy

of Needs

Maslow’s

Hierarchy

of Needsin a hospital

breathing, circulation, temperature,

intake of food and fluids, elimination of

wastes, movement

Maslow’s

Hierarchy

of Needsin a hospital

housing, community, climate, family

Maslow’s

Hierarchy

of Needsin a hospital

relationships with others, communications

with others, support systems, being part of

community, feeling loved by others

Maslow’s

Hierarchy

of Needsin a hospital

hope, joy, curiosity, happiness,

accepting Self

Maslow’s

Hierarchy

of Needsin a hospital

thinking, learning, decision making,

values, beliefs, fulfillment, helping others

Maslow’s

Hierarchy

of Needs

updated?

Maslow’s

Hierarchy

of Needs

updated

What has changed?

Maslow’s Hierarchy of Needs

revisited by Douglas T. Kenrick, VladasGriskevicius, Steven L. Neuberg, and Mark Schaller; 2010

Perhaps the most obvious change is that “self-actualization” has been rolled into “status/esteem” as it is not exactly a distinct human need.

We see the evolutionary need of reproductive goals at the top of the pyramid. For us in healthcare, we know that people have to be as healthy as possible in order to achieve these goals.

Even with these developments at the interface of evolutionary biology, anthropology, and psychology, we can see how the Emergency Department canmeet several needs of the Super Utilizer.

Even though the

emergency

department

provides excellent

care, should it

strive to meet all

the needs of the

patient?

What is best for

the patient?

How can the ED determine

the most appropriate care plan for

a patient?

What is ED’s responsibility to patient?

What is best for

the system?

A study out of the Yale Global Health

Leadership Institute found that a patient’s

overall heath is determined by

20% genetics 20% healthcare

60% social determinants of

health

What are the Social Determinants of Health?

ID/Documents

1. Do you have a

valid government

issued ID?

Food

2. Do you eat less

than you feel you

should because

there's not enough

food?

Housing

3. Are you worried

that in the next few

months, you may not

have safe housing

that you own, rent or

share?

Utilities

4. In the past year,

have you had a hard

time paying your

utility company bills?

Clothing

5. Are you in need of

clothing to meet your

daily needs?

Finances

6. Are your finances

covering your living

costs?

Transportation

7. Do you have a

dependable way to

get to work or school

and your

appointments?

Education

8. Do you think

completing more

education or training

would be helpful to

you?

Employment

9. Do you have a job

or other steady

source of income?

Medical Home

10. Do you have a

usual source of

medical care?

Insurance

11. Do you have

medical insurance?

Childcare

12. Does getting

childcare make it

hard for you to work,

go to school or

study?

Social Support

13. Do you have

people in your life

that you feel

supported by?

Prescription Access

14. Have you

experienced a time

when finances got in

the way of being

able to cover your

costs for your

prescriptions?

Consent to Help

15. Would you like to

receive assistance

with any of these

needs?

General

16. Are any of your

needs urgent? For

example, I don't have

food tonight or I don't

have a place to

sleep tonight?

What can you do?

Integrating social determinates of health can help you

to better assess and understand your patients.

Example: Insulin that must be kept cold

What could the physician have done differently?

What are others doing?

The Patient Care Intervention

Center, Harris County,

Houston, Texas Provides care coordination for “High-Needs, High Cost” patients with 2+ chronic conditions who frequent

the emergency room using a patient driven goals based model.

The multidisciplinary team (social workers, community health workers, medical assistants, RNs, and MDs)

coordinates care in relation to the patient’s PCP and specialist appointments, pharmacy (medication

reconciliation), as well as transportation, social security benefits, housing, and food insecurities.

The intervention period ranges from 2-6 months and is concluded with a warm handoff back to the primary

care home or referral source.

Conclusions

Although the social needs of a Super

Utilizer have been traditionally viewed

as a social problem, it has become a

healthcare problem.

Looking at treatment through a

different lens can lead to more

effective outcomes in a more efficient

manner.

References Agency for Healthcare Research and Quality. (2016). Pathways Community HUB Manual: A

Guide to Identify and Address Risk Factors, Reduce Costs, and Improve Outcomes (AHRQ Publication No. 15(16)-0070-EF). Retrieved from https://innovations.ahrq.gov/sites/default/files/ Guides/CommunityHubManual.pdf.

Bradley, E.H. & Taylor, L.A. (2013). The American Health Care Paradox: Why Spending More Is Getting Us Less. New York, NY: PublicAffairs.

Capital Healthcare Planning. (2018). Bexar County High Utilizer/Homeless Healthcare Analysis.

Health Leads, Inc. (2016). Social Needs Screening Tool Kit. Retrieved from https://healthleadsusa.org/wp-content/uploads/2016/07/Health-Leads-Screening-Toolkit-July-2016.pdf.

https://pcictx.org/

Kenrick, D.T., Griskevicius, V., Neuberg, S.L., & Schaller, M. (2010). Renovating the Pyramid of Needs: Contemporary extensions built upon ancient foundations. Perspectives on Psychological Science, (vol. 5, pp. 292–314).

Maslow, A.H. (1943). A Theory of Human Motivation. Psychological Review. (vol. 50, pp. 370–396).

TAVHealth. Social Determinates of Health Assessment.

Taylor, Carol. (2015) Fundamentals of Nursing: The Art and Science of Person-centered Nursing Care. 8th ed. Philadelphia, PA: Wolters Kluwer.